Geriatrics Peer Review

Th Pepersack, President F Schildermans, Vice-President JP Baeyens, Secretaire

Peer Review, Geriatrics 2000-2001

OUTCOMES OF CONTINUOUS PROCESS IMPROVEMENT

OF NUTRITIONAL CARE PROGRAM AMONG GERIATRIC

UNITS IN BELGIUM

Introduction

Up to 65% of elderly patients are protein-energy undernourished (PEU) at admission or acquire nutritional deficits while hospitalised

PEU is associated with: high hospitalisation stay high morbidity and mortality high rehospitalisation rate

Aims

to assess the quality of care concerning nutrition among Belgian geriatric units

to include more routinely nutritional assessments and interventions into comprehensive geriatric assessment

to assess the impact of nutritional recommendations on nutritional status an on the length of hospitalisation

Methodology

Prospective survey of consecutive admissions between January and June 2001

Comprehensive geriatric assessmentNutritional assessment (MNA & PAB &

Lymphocyte)

two phases project design: Observational Interventional

0 3 6 months

Methodology: 2 phases

ObservationComprehensive

geriatric assessment and MNA

Routine nutrition

InterventionComprehensive

geriatric assessment and MNA

« Flow Chart»« Meals on

Wheels » approach

0 3 6 months

FLOW CHART SUGGESTING A RATIONAL APPROACH TO THE MANAGEMENT OF MALNUTRITION

MNA <23.5 points and/or PAB<0.2 g/l

START CALORIC SUPPLEMENTATION RULE OUT TREATABLE CAUSES/ UTILIZE MEALS-

ON-WHEELS APPROACH

IF PAB FAILS TO RISE CONSIDER ENTERAL (or parenteral) NUTRITION

CHECK PAB AT DISCHARGE

Morley 1994

The « meals-on-wheels » approachThe « meals-on-wheels » approach

MMedicaments EEmotions AAnorexia LLate life paranoia SSwallowing

(déglutition)

OOral problems NNo money

WWandering, (comportements)

HHyperthyroidie, HPT1 EEntry (malabsorption) EEating problems

(fiche) LLow salts, low chol

diets SShopping

Outcomes

to assess the quality of care concerning nutrition among Belgian geriatric units descriptive statistics of nutritional status during phase 1

to include more routinely nutritional assessments and interventions into comprehensive geriatric assessment sensitize the teams to nutritional aspect of the comprehensive

geriatric assessment

to assess the impact of nutritional recommendations on nutritional status an on the length of hospitalisation comparison of nutritional parameters and hospitalisation

stays between phase 1 and phase 2

Statistics

Data will be collected in a data base using the software Access from Microsoft

statistical analyses will be performed with the software Statistica 5 Microsoft.

Results from groups of patients will presented as meansSD.

Non parametric Mann Whitney test will be used to compare means between the periods of the study (observational phase versus intervention phase).

Z-score with Yates correction will be used to assess the differences between proportions of conditions.

References

1. Anderson MD, Collins G, Davis G, Bivins BA. Malnutrition and length of stay : a relationship ? Henry Ford Hosp Med J 1985 ;59 :477-483.

2. Klidjian AM, Archer TJ, Foster KJ, Karran SJ. Detection of dangerous malnutrition. J Parenter Enteral Nutr 1982 ; 6 : 119-121.

3. Mullen JL, Gertener MH, Buzby GP, Goodhart GL, Rosato EF. Implications of malnutrition in the surgical patient. Arch Surg 1979 ; 114 : 121-125.

4. Constans T, Bacq Y, Brechot JF, Guilmot JL, Choutet P, Lamisse F. Protein-energy malnutrition in elderly medical patients. J Am Geriatr Soc 1992 ; 40 : 263-268.

5 . Sullivan DH, Walls RC, Lipschitz DA. Protein-energy undernutrition and the risk of mortality within one year of hospital discharge in a select population of geriatric rehabilitation patients. Am J Clin Nutr 1991 ; 53 :599-605.

6. Weinsier RL, Hunker EM, Krumdieck CL, Butterwoth CE Jr. Hospital malnutrition : a prospective evaluation of general medical patients during the course of hospitalization. Am J Clin Nutr 1979 ; 32 : 418-426.

7. Mears E. Outcomes of continuous process improvement of nutritional care program incorporating serum prealbulmin measurements. Nutrition 1996 ; 12 (7/8) : 000-000.

8. Vellas B, Garry PJ, Albarede JL. Nutritional assessment as part of the geriatric evaluation : the mini nutritional assessment. Facts, Research and Intervention in Geriatrics 1997, pp 11-13 . Serdi Publishing Compagny, 3rd Edition, Vellas B, Guigoz Y, Garry P, Albarede J, editors.

9. Guigoz Y, Vellas B, Garry PJ. Mini Nutritional Assessment : a practical assessment tool for grading the nutritional state of elderly patients. Facts, Research and Intervention in Geriatrics 1997, pp 15-60 , Serdi Publishing Compagny, 3rd Edition, Vellas B, Guigoz Y, Garry P, Albarede J, editors.

10. Morley JE. Nutrition assessment is a key component of geriatric assessment. Facts, Research and Intervention in Geriatrics 1997, pp 11-13 . Serdi Publishing Compagny, 3rd Edition, Vellas B, Guigoz Y, Garry P, Albarede J, editors.

annexes

Mini Nutritional Assesment (MNA)

Indices Indices anthropométriquesanthropométriques BMI, CB, CM perte de poids récente

Evaluation globaleEvaluation globale indépendant à domicile plus de 3 médicaments maladie aiguë ou stress motricité probl neuropsy escarres

Indices diététiquesIndices diététiques combien de repas/jour produits laitiers, œufs,

légumes, viande, poisson, volaille

appétit combien de verre/jour se nourrit seul, avec

difficulté

Evaluation subjectiveEvaluation subjective

Guigoz et al. facts Res Gerontol 1990

Project Management

ActionsPresentation

(2000)protocol sendingSoftware creation

for registrationcentre recruitment

Implementations Data collect 1srt phase Mail for the 2nd phase

(March, 2001) Data collect 2nd phase

(July 2001) Preliminary report (July

2001) Feed back Questionnaire

Project presentation

SBGG meeting Liège,

News-groupSBGG mailing G-NewsRepeated Mails

Octobre 2000250 participants

November 2000

December 2000400 members

protocole sending

December 2000Including:

protocole Word Encoding Software

Access Numeric Scales

Word Presentation Power

Point 33 centres answered

Results

12 centers presented evaluable dataN=1139 admissions

Characteristics of 1140 consecutive admissions between January and June 2001.

STAY (days)

No

of

ob

s

0

66

132

198

264

330

396

462

-40 0 40 80 120 160 200 240

MNA (points)

No

of

ob

s

0

42

84

126

168

210

252

294

-5 0 5 10 15 20 25 30 35

Characteristics of 1140 consecutive admissions between January and June 2001.

Characteristics of the patients according to period.Phase I: observational period; phase II: interventional period.

Phase I Phase II Valid

N Mean or %

Std.Dev. Valid N

Mean or %

Std.Dev. p

WOMEN 70% 70% ,878141 STAY (day) 632 27,1 21,9 354 21,7 15,1 ,000046 AGE (yr) 669 82,8 7,3 428 83,1 7,2 ,410498 MiniMNA(points) 437 8,3 3,2 197 8,7 3,2 ,096389 MNA (points) 538 17,9 5,5 295 18,2 5,4 ,572510

±Std. Dev.

±Std. Err.

Mean

Phase 1 Phase 2

STA

Y (

da

ys

)

0

10

20

30

40

50

60

Characteristics of the patients according to period.Phase I: observational period; phase II: interventional period.

Characteristics of the patients according to period.Phase I: observational period; phase II: interventional period.

Phase I Phase II Valid N Mean Std.Dev. Valid

N Mean Std.Dev. p

PAB variations (g/l)

483 -,007 ,094 278 ,009 ,144 ,045595

CRP variations 585 -2,2 10,5 328 -1,0 23,1 ,276841 Lymphocytes count variations

626 55 472 340 48 574 ,838543

Determinant of admission PAB

Determinant of admission PAB

Comparison between admission and discharge a) for the whole group

Comparison between admission and discharge b) phase I:

c) phase II:

Determinants of hospitalisation stay:

Determinants of hospitalisation stay:

Hospital comparisons

±Std. Dev.

±Std. Err.

Mean

Hospital

MN

A (

poin

ts)

4

8

12

16

20

24

28

4 6 7 9 10 11 12 15 18 19 25 28

±Std. Dev.

±Std. Err.

Mean

Hospital

Ad

mis

sio

n P

AB

(g

/l)

0,08

0,14

0,20

0,26

0,32

0,38

0 4 6 7 9 10 11 12 15 18 19 25 28

±Std. Dev.

±Std. Err.

Mean

Hospital

AG

E (

yr)

70

74

78

82

86

90

94

4 6 7 9 10 11 12 15 18 19 25 28

±Std. Dev.

±Std. Err.

Mean

Hospital

Ad

mis

sio

n C

RP

(m

g/1

00

ml)

-10

-5

0

5

10

15

20

25

30

35

4 6 7 9 10 11 12 15 18 19 25 28

±Std. Dev.

±Std. Err.

Mean

HOSPITAL

Ad

mis

sio

n L

ymp

ho

cyte

s co

un

t (p

er

mm3

)

200

600

1000

1400

1800

2200

2600

4 6 7 9 10 11 12 15 18 19 25 28

±Std. Dev.

±Std. Err.

Mean

HOSPITAL

STA

Y (

da

ys)

-10

10

30

50

70

90

4 6 7 9 10 11 12 15 18 19 25 28

±Std. Dev.

±Std. Err.

Mean

HOSPITAL

Ad

mis

sio

n P

AB

/CR

P r

atio

-1,2

-0,8

-0,4

0,0

0,4

0,8

1,2

1,6

2,0

4 6 7 9 10 11 12 15 18 19 25 28

Discharge parameters

±Std. Dev.

±Std. Err.

Mean

HOSPITAL

Dis

cha

rge

PA

B (

g/l)

-0,05

0,00

0,05

0,10

0,15

0,20

0,25

0,30

0,35

0,40

4 6 7 9 10 11 12 15 18 19 25 28

±Std. Dev.

±Std. Err.

Mean

HOSPITAL

Dis

cha

rge

CR

P (

mg

/10

0m

l)

-10

0

10

20

30

40

50

4 6 7 9 10 11 12 15 18 19 25 28

±Std. Dev.

±Std. Err.

Mean

HOSPITAL

Dis

cha

rge

Lym

ph

ocy

tes

cou

nt

(pe

r m

m3)

200

600

1000

1400

1800

2200

2600

3000

4 6 7 9 10 11 12 15 18 19 25 28

±Std. Dev.

±Std. Err.

Mean

HOSPITAL

Dis

cha

rge

PA

B/C

RP

ra

tio

-0,4

-0,2

0,0

0,2

0,4

0,6

0,8

1,0

1,2

4 6 7 9 10 11 12 15 18 19 25 28

Parameters variations

±Std. Dev.

±Std. Err.

Mean

HOSPITAL

PA

B v

ari

atio

ns

(g/l)

-0,3

-0,2

-0,1

0,0

0,1

0,2

0,3

4 6 7 9 10 11 12 15 18 19 25 28

±Std. Dev.

±Std. Err.

Mean

HOSPITAL

CR

P v

ari

atio

ns

(mg

/10

0m

l)

-50

-40

-30

-20

-10

0

10

20

30

40

4 6 7 9 10 11 12 15 18 19 25 28

±Std. Dev.

±Std. Err.

Mean

HOSPITAL

Lym

ph

ocy

tes

cou

nts

va

ria

tion

s (p

er

mm3 )

-1200

-800

-400

0

400

800

1200

1600

2000

4 6 7 9 10 11 12 15 18 19 25 28

±Std. Dev.

±Std. Err.

Mean

HOSPITAL

PA

B/C

RP

ra

tio v

ari

atio

ns

-1,6

-1,0

-0,4

0,2

0,8

1,4

2,0

4 6 7 9 10 11 12 15 18 19 25 28

Conclusions

Conclusions

High prevalence of malnutrition among geriatric hospitalized patients

Significant decreased hospitalization stay during 2nd phase (Confounding factor?)

Significant increased PAB concentrations during 2nd phase

Conclusions

By multiple regression analysis, hospitalization stay is determined by admission PAB/CRP (inverse correlation) and Mini-MNA

Quite homogeneous hospital data distribution

Data comparable with those of medical literature